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Officials promise progress on health investigations


Maryland's top health official said yesterday he will order his staff to improve investigations of deaths and serious injuries at state-licensed facilities, and a legislator added he intends to ensure that happens.

Dr. Georges Benjamin, secretary of the Department of Health and Mental Hygiene, said his staff will study states around the country to see how they investigate serious incidents and then make proposals to improve Maryland's practices.

He made his remarks at a legislative budget hearing of the Subcommittee on Health and Human Resources. He was responding to testimony from advocates for the developmentally disabled who harshly criticized the way deaths and injuries have been investigated by his department.

The advocates noted a case in yesterday's editions of The Sun that described the investigation into the death of Mark Bittner, a 30-year-old brain-damaged patient at Rosewood Center, a state-operated facility in Owings Mills.

Bittner died in December 2000 while being restrained by five staff members. He had stopped breathing for at least 14 minutes before anyone at Rosewood called for an ambulance, and the medical examiner said the restraint and overmedication played a part in his death.

Those issues - and 20 cuts and bruises discovered on Bittner's neck and body - were not addressed by state health care investigators from Benjamin's department.

Kenneth Wardlaw, an attorney for the Maryland Disability Law Center, told legislators that the entire structure for investigating deaths is flawed. The law center is a federally and state-mandated advocacy and watchdog group.

Too much secrecy surrounds deaths and serious injuries at state facilities, Wardlaw said, and an inherent conflict of interest exists because it is the responsibility of one branch of the health department to investigate deaths at facilities operated by another branch.

"You have the fox guarding the hen house," he said. "We feel there needs to be, perhaps, independent oversight of these incidents."

Benjamin said he was open to suggestions from advocates and others about how to investigate deaths and other serious incidents. His department's Office of Health Care Quality investigates places such as Rosewood, which is run by another department agency, the Developmental Disabilities Administration.

"We're committed to quality," Benjamin said after the hearing. "It appears that we may need to make some changes, and if that turns out to be the case, we will."

Wardlaw and others say investigations of the facilities by state police are not adequate because they are looking for criminal acts and not violations of Maryland health care regulations. Unless the investigations are more thorough, they say, policies for avoiding deaths and injuries in similar circumstances won't be developed.

They point to a case in May that demonstrates the cursory nature of the health care investigations. In that case, Carlton Thomas, a special education student at the Edgemeade School in Prince George's County, died while being restrained by staff members. Health care investigators found no problems with the way he was restrained, but state prosecutors charged one of the staff members with manslaughter.

Lauren Young, legal director for the legal center, said dozens of serious incidents have occurred in Maryland's four largest facilities, yet the Office of Health Care Quality has not found a single serious problem at any of them.

"I find that amazing," she said. "I find that unbelievable."

Bittner's parents have complained that their questions about their son's death were never answered by any Maryland official. Worse, they said, they were refused access to a 2 1/2 -page report completed by the Office of Health Care Quality. The report has not been made public because Maryland health officials say privacy laws prevent that, but those who have read it say it never mentions Bittner's parents' concerns. Del. Robert L. Flanagan said the health department might be misinterpreting the law, and, if not, privacy considerations probably should be changed - with the way serious incidents are investigated.

"I think there are some situations when someone gets hurt or when someone dies where the family is the best advocate these people have," the Howard County Republican said.

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